Fee for Service Outpatient Changes For Psychiatric Services Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Agenda Who is Optum? Medi-Cal Managed Care Plans (MCP) Title 9 Medical Necessity Fee for Service (FFS) Outpatient Target Population Treatment Philosophy Mental Health Severity Analysis Authorization Process Accessing Forms Partnerships Resources Contact Information Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Who is Optum? Optum is the Administrative Service Organization for the County of San Diego, Behavioral Health Services Division Contract includes, but is not limited to: Operation of the San Diego County Access and Crisis Line (ACL) and Utilization Management (UM) Through the ACL, Optum provides 24 hour crisis intervention, suicide prevention and behavioral health referrals. Through UM, Optum provides authorizations for Mental Health and Residential Substance Use Disorders Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

MCP- Medi-Cal Background In January 2014, the Department of Health Care Services (DHCS) for the State of California obligated the Medi-Cal Managed Care Plans (MCPs) to provide mental health services to beneficiaries with mild to moderate impairment of mental, emotional, or behavioral functioning. Each MCP has its own network of contracted behavioral health providers to serve their beneficiaries. You might also be on one or more of these networks. The County Mental Health Plan, consisting of County Clinics, Organizational Providers, and the Optum Public Sector FFS Network is targeted to provide services to those individuals with more severe behavioral health impairment. It should be noted that California Regulation Title 9 is the basis for all Specialty Mental Health Services for Medi-Cal Beneficiaries and in some cases a mild presentation or moderate can meet title 9 medical necessity. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Medi-Cal Managed Care Plans There are seven Managed Care Plans (MCPs) who provide Health Plan options to San Diego Medi-Cal beneficiaries, you may be contracted with one or more of the MCPs as well. Aetna Better Health, Care1st, Community Health Group, Health Net, Kaiser, Molina and UnitedHealthcare. MCPs cover beneficiaries’ medical needs, transportation to Medi-Cal covered services and mild to moderate outpatient behavioral health needs and Applied Behavioral Analysis Treatment. Beneficiaries may change Managed Care Plans, and in rare circumstances, they may not have a MCP; County will assume responsibility if there is no assigned MCP as long as the clinical presentation meets Title 9 medical necessity. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Community Health Group Contact Information for MCP Behavioral Health Services Health Plan Medi-Cal Managed Care Plan Behavioral Health Services Aetna Better Health (855) 772-9076 Care1st Health Plan Care1st.com Care1st Health Plan (855) 321-2211 Community Health Group Chgsd.com Behavioral Health Services (800) 404-3332 Health Net HealthNet.com Managed Health Network (MHN) (888) 426-0030 Kaiser Permanente KP.org Kaiser Permanente, Department of Psychiatry (877) 496-0450 Molina Healthcare MolinaHealthcare.com (888) 665-4621 UnitedHealthcare (866) 270-5785 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

California Code of Regulations- Title 9 Medical Necessity Criteria Available on DHCS website: http://www.dhcs.ca.gov/services/MH/Documents/Title9MedicalNecessityCriteria.pdf Requires an approved DSM IV primary diagnosis Requires a significant impairment in an important area of life functioning or for children developmental progress is at risk The focus of treatment must be on the primary DSM IV diagnosis, exclusions include, Autism, Primary Substance use disorders, Anti-Social Personality Disorder and Mental Health issues due to a known medical condition The intervention will diminish the impairment, prevent deterioration, and support the child to progress developmentally The condition would not be responsive to physical health treatment Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Fee for Service (FFS) Population Adults with serious and persistent psychiatric illness requiring complex biopsychosocial services to maintain stability Adults with an approved DSM IV primary diagnosis and focus of treatment must be on the primary DSM IV diagnosis Adults with a significant impairment in an important area of life functioning and the condition would not be responsive to physical health treatment Children with a DSM IV diagnosis with behavior inappropriate to the child’s age according to developmental norms and a substantial impairment in two areas of life functioning Children at risk of removal from home/have been removed from home OR the impairment has lasted more than six months Children and adults presenting with clinical risk: psychosis, suicidal ideation, and/or violence Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Treatment Philosophy of the Fee for Service Network The Recovery Model: Clinical improvement and self sufficiency is possible, but challenges during the process may occur along the way The role of the provider is to stabilize the client by utilizing goal focused treatment targeting the specific mental health condition The treatment intervention will diminish the impairment or prevent deterioration Authorizations-based on Title 9 Medical Necessity regulations Available on DHCS website: http://www.dhcs.ca.gov/services/MH/Documents/Title9MedicalNecessityCriteria.pdf Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

The Adult Mental Health Severity Analysis/Screening The severity index and other information on target population is available at: optumsandiego.com The County of San Diego and the Medi-Cal MCPs worked together to develop criteria and tools A shared conceptual framework and a useful guide regarding mild, moderate, and severe criteria to assess with clinical perspective The Severity Analysis Tool is not applicable to children Uses four elements: Risk, Clinical Complexity, Life Circumstances, and Benefit of Integrated Care Use of guide is recommended to ensure assessment alignment across System of Care, all determinations are based on Title 9 Medical Necessity Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Adult Mental Health Severity Analysis – Symptom Examples FFS and/or other County Providers Acute risk for SI/harm to others Psychosis Cognitive Impairment Impulsive/Aggressive Seriously incapacitated in daily activities Many Mental Health hospitalizations On conservatorship Chronic Mental Health conditions MCP Behavioral Health Situational issue: loss, break-up, major life change Disruption in relationships resulting in extreme distress Excessive truancy or suddenly failing school Likely to be resolved in 6 mo. or less Stable on meds for 1 yr. or longer San Diego County Access and Crisis Line 888-724-7240 Operates 24 Hours a day, 7 days per week Provides Suicide Prevention, Crisis Intervention and Referrals Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11

The Process-Referrals and Screening *The severity analysis is not applicable to children/adolescents Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

The Process, Obtaining Initial Authorization *The severity analysis is not applicable to children/adolescents Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

The Process, Obtaining Continuing Authorization Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Accessing Forms Website: www.optumsandiego.com Select: “County and Staff Providers” Then, select: “Fee for Service Providers” Click on “Forms” Look for Outpatient Authorization Request- Psychiatry Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Forms-Demographic Form (At Auth Request Or If Updates) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Forms-Outpatient Authorization Request (OAR-Psychiatry) Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

The Process-Authorization Increments Assessments do not require pre-authorization Follow up sessions will be given at a maximum of 26 sessions per OAR- Psychiatry submission (typically at 2 times per month) and you may request the frequency that is clinically indicated Team Conferencing & Case Management Sessions are also available upon request Group sessions are also available, but should focus on the client’s mental health diagnosis or impairment All Authorizations are based on California Title 9 Medical Necessity for Specialty Mental Health Services Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Forms-Interpreter Services The MHP covers the cost Request for Interpreter Services Form is available on our website- www.optumsandiego.com, County and Staff Providers, Fee For Service Providers, Forms Must be submitted via fax AT LEAST 2 business days prior to appt., or as soon as appt. is set Incomplete forms will be sent back and will cause delays in processing Do not sign the document-Optum is the entity approving the service Follow the instructions and fill out ALL highlighted areas (2pages)-complete “form fill” online or print out in color Submit form to Optum before 1st appt. of new authorization period Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Partnerships Coordination of Care is Essential Managed Care Plans Primary Care Physicians Psychiatrists Case Managers TBS workers Protective Service Workers Probation Teachers Therapists Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Contact Information-Optum Medi-Cal Provider Line 1-800-798-2254 Option 2 Claims Option 3 Authorizations Option 3 Provider Clinical Questions Option 4 Provider Administrative Questions Option 7 Provider Services Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Wrap up Reminders We are here to help! Call us! Medi-Cal Provider Line 800-798-2254 Option 3, Option 3 Mild to Moderate needs can be served by the client’s Managed Care Plan, Severe needs Fee for Service, Clinics or FQHCs All authorizations are based on California Title 9 Medical Necessity The role of the provider is to utilize goal-focused treatment targeting the specific mental health condition There is an array of Recovery focused organizations in our County, please refer to all appropriate community supports Call Access and Crisis Line 888-724-7240 for additional referrals or resources Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

For Questions please call the Provider Line Thank you! For Questions please call the Provider Line Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.